METHODS: ENACT-HF was an international, multicenter, open-label, pragmatic, 2-phase study, comparing the current standard of care of each center with a standardized diuretic protocol, including urinary sodium to guide therapy. The primary end point was natriuresis after 1 day. Secondary end points included cumulative natriuresis and diuresis after 2 days of treatment, length of stay, and in-hospital mortality. All end points were adjusted for baseline differences between both treatment arms.
RESULTS: Four hundred one patients from 29 centers in 18 countries worldwide were included in the study. The natriuresis after 1 day was significantly higher in the protocol arm compared with the standard of care arm (282 versus 174 mmol; adjusted mean ratio, 1.64; P<0.001). After 2 days, the natriuresis remained higher in the protocol arm (538 versus 365 mmol; adjusted mean ratio, 1.52; P<0.001), with a significantly higher diuresis (5776 versus 4381 mL; adjusted mean ratio, 1.33; P<0.001). The protocol arm had a shorter length of stay (5.8 versus 7.0 days; adjusted mean ratio, 0.87; P=0.036). In-hospital mortality was low and did not significantly differ between the 2 arms (1.4% versus 2.0%; P=0.852).
CONCLUSIONS: A standardized natriuresis-guided diuretic protocol to guide decongestion in acute heart failure was feasible, safe, and resulted in higher natriuresis and diuresis, as well as a shorter length of stay.
STUDY DESIGN: A cross-sectional survey was done involving 707 different flavours and packaging of instant noodles sold in six hypermarkets and retailer chains in Malaysia and the corresponding brand's official websites in 2017.
METHODS: The salt content (gram per serving and per 100 g) was collected from the product packaging and corresponding brand's official website.
RESULTS: Of the 707 different packaging and flavours of instant noodles, only 62.1% (n=439) provided the salt content in their food label.The mean (±SD) salt per 100 g of instant noodles was 4.3±1.5 g and is nearly four times higher than the salt content of food classified in Malaysia as a high salt content (>1.2 g salt per 100 g). The salt content for instant noodle per packaging ranged from 0.7 to 8.5 g. 61.7% of the instant noodles exceeded the Pacific Salt Reduction Target, 11.8% exceeded the WHO recommended daily salt intake of <5.0 per day and 5.50% exceeded Malaysia Salt Action Target. 98% of instant noodles will be considered as high salt food according to the Malaysia Guidelines.The probability of the instant noodles without mixed flavour (n=324) exceeding the Pacific Salt Reduction Target was tested on univariate and multivariate analysis. Instant noodles with soup, Tom Yam flavour, pork flavour and other flavours were found to be predictors of instant noodles with the tendency to exceed Pacific Salt Reduction Target when compared with instant noodles without mixed flavours (p<0.05).
CONCLUSION: Only 62% of instant noodles displayed the salt content on their food label. Salt content in instant noodles is very high, with 90% exceeding the daily salt intake recommended by WHO. Prompt action from regulatory and health authorities is needed to reduce the salt content in instant noodles.
CASE PRESENTATION: We present the case of a 37-year-old Malay gentleman with underlying type 2 diabetes mellitus on empagliflozin, who presented to our hospital with symptomatic coronavirus disease 2019 infection and diabetic ketoacidosis. He developed severe rebound euglycemic diabetic ketoacidosis due to the continuous usage of empagliflozin for glycemic control alongside intravenous insulin.
CONCLUSIONS: Physicians should have a high index of suspicion in diagnosing and managing euglycemic diabetic ketoacidosis, including withholding treatment of sodium-glucose cotransporter 2 inhibitors during the acute management of diabetic ketoacidosis.